Get Medical/hra Claim Submission / Withdrawal Request Form

Filing a Medical/HRA Claim Submission / Withdrawal Request Form online can be a straightforward process. Following this guide will help ensure that your claim is submitted correctly and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the claim submission form and open it for editing.
2. Complete Part 1 thoroughly and legibly. This section requires you to input your personal information including your name, member ID, mailing address, employer name, telephone number, and email. Be sure to notify your benefits administrator of any address changes.
3. In Part 2, select the appropriate type of claim option. You may choose from new claim, resubmission, eClaim documentation, or debit card documentation.
4. Proceed to Part 3 where you will itemize each healthcare expense. For each entry, provide the date of service, type of claim (such as medical, prescription, over-the-counter, vision, dental, or hearing), patient name, provider name, description of the service, and the amount charged.
5. Ensure all documentation is complete. Attach itemized receipts and any required documentation, such as your insurance carrier’s explanation of benefits (EOB) for medical, dental, or vision claims.
6. Read and sign the Certification for Reimbursement section at the end of the form, ensuring that you acknowledge the information you have provided is accurate and that you have not previously requested reimbursement for these expenses.
7. Once completed, save your changes and make a copy of the filled-out form and documentation for your personal records.
8. Finally, mail or fax the completed form and all necessary documentation to UnitedHealthcare at the address or fax number provided on the form. Ensure it is sent before the outlined deadline.

Take the next step and complete your Medical/HRA Claim Submission / Withdrawal Request Form online.